Chapter 9:Neurosis(4) Somatoform Disorders

1
Chapter 9Neurosis(4)Somatoform Disorders

• Zhonghua Su, P.h D MD
• Jining Medical University

2
Introduction (1)

• According to the fourth edition of Diagnostic and
  Statistical Manual of Mental Disorders (DSM-IV),
  the somatoform disorders are distinguished by
  physical symptoms suggesting a medical condition,
  yet the symptoms are not fully explained by the
  medical condition, by substance use, or by
  another mental disorder.
• The symptoms are severe enough to cause patients
  significant distress or impaired social,
  occupational, or other functioning.
• The physical symptoms of somatoform disorders are
  not intentionally produced as are those of
  factitious disorders and malingering, but no
  medical condition can fully explain the somatic
  symptoms.
• Clinicians must judge that the onset, severity,
  and duration of symptoms are strongly linked to
  psychological factors to diagnose a somatoform
  disorder.

3
Introduction (2)

• In DSM-IV, five specific somatoform disorders are
  recognized
• somatization disorder, characterized by many
  physical complaints affecting many organ systems
  
• conversion disorder, characterized by one or two
  neurological complaints
• hypochondriasis, characterized less by a focus on
  symptoms than by patients' beliefs that they have
  a specific disease
• body dysmorphic disorder, characterized by a
  false belief or exaggerated perception that a
  body part is defective and
• pain disorder, characterized by symptoms of pain
  that are either solely related to or
  significantly exacerbated by psychological
  factors.
• DSM-IV also has two residual diagnostic
  categories for somatoform disorders
  Undifferentiated somatoform disorder includes
  somatoform disorders not otherwise described that
  have been present for 6 months or longer and
  somatoform disorder not otherwise specified is
  the category for somatoform symptoms that do not
  meet any of the previously mentioned somatoform
  disorder diagnoses.

4
Classification (DSM -IV)

• somatization disorder,
• conversion disorder
• hypochondriasis
• body dysmorphic disorder
• pain disorder
• Undifferentiated somatoform disorder
• somatoform disorder not otherwise specified

5
Introduction (3)

• The categories of somatoform disorders are
  similar in ICD-10 and DSM-IV, except that in
  ICD-10, body dysmorphic disorder is a
  subcategory.
• ICD-10 also stresses that differential diagnosis
  of somatoform disorders requires that a clinician
  know the patient well.
• A patient's "degree of conviction" may be
  temporarily lessened by a clinician's assurances
  and by a physical examination, but the disorders
  are a culturally accepted way of exhibiting
  physical illness and explaining physical
  symptoms.

6
Somatization Disorder
7
Introduction (1)

• characterized by many somatic symptoms
• distinguished by "a combination of pain,
  gastrointestinal, sexual, and pseudoneurological
  symptoms."
• begins before the age of 30
• may continue for years
• multiplicity of the complaints and the multiple
  organ systems (differ from others)
• associated with significant psychological
  distress
• impairment in social and occupational
  functioning
• excessive medical-help seeking behavior.

8
Introduction (2)--history

• Somatization disorder has been recognized since
  the time of ancient Egypt. An early name for
  somatization disorder was hysteria, a condition
  incorrectly thought to affect only women. (The
  word hysteria is derived from the Greek word for
  uterus, hystera.)
• In the 17th century, Thomas Sydenham recognized
  that psychological factors, which he called
  antecedent sorrows, were involved in the
  pathogenesis of the symptoms.
• In 1859, Paul Briquet, a French physician,
  observed the multiplicity of the symptoms and the
  affected organ systems and commented on the
  usually chronic course of the disorder.
• Because of these astute clinical observations,
  the disorder was called Briquet's syndrome for a
  time, although the term somatization disorder
  became the standard in the United States when the
  third edition of DSM (DSM-III) was introduced in
  1980.

9
Epidemiology (1)

• The lifetime prevalence of somatization disorder
  in the general population is estimated to be 0.1
  or 0.2 percent, although several research groups
  believe that the actual figure may be closer to
  0.5 percent.
• Women with somatization disorder outnumber men 5
  to 20 times, but the highest estimates may be due
  to the early tendency not to diagnose
  somatization disorder in male patients.
  Nevertheless, it is not an uncommon disorder.
  With a 5-to-1 female-to-male ratio, the lifetime
  prevalence of somatization disorder among women
  in the general population may be 1 or 2 percent.

10
Epidemiology (2)

• Among patients in the offices of general
  practitioners and family practitioners, as many
  as 5 to 10 percent may meet the diagnostic
  criteria for somatization disorder.
• The disorder is inversely related to social
  position and occurs most often among patients who
  have little education and low income levels.
• Somatization disorder is defined as beginning
  before age 30 it most often begins during a
  person's teenage years.
• Several studies have noted that somatization
  disorder commonly coexists with other mental
  disorders.

11
Etiology

• Psychosocial Factors
• interpretations of the symptoms as social
  communication
• avoid obligations
• express emotions
• symbolize a feeling or a belief
• the symptoms substitute for repressed instinctual
  impulses
• A behavioral perspective
• Biological Factors
• characteristic attention and cognitive
  impairments
• decreased metabolism in the frontal lobes and in
  the nondominant hemisphere
• genetic components
• Research into cytokines

12
Clinical Features (1)

• many somatic complaints and long, complicated
  medical histories
• most common symptoms nausea and vomiting,
  difficulty in swallowing, pain in the arms and
  legs, shortness of breath unrelated to exertion,
  amnesia, and complications of pregnancy and
  menstruation
• Patients frequently believe that they have been
  sickly most of their lives.

13
Clinical features -2

• Psychological distress and interpersonal problems
  are prominent anxiety and depression are the
  most prevalent psychiatric conditions.
• Suicide threats are common, but actual suicide is
  rare. If suicide does occur, it is often
  associated with substance abuse.
• Patients' medical histories are often
  circumstantial, vague, imprecise, inconsistent,
  and disorganized. Patients classically but not
  always describe their complaints in a dramatic,
  emotional, and exaggerated fashion, with vivid
  and colorful language they may confuse temporal
  sequences and cannot clearly distinguish current
  from past symptoms.
• Female patients with somatization disorder may
  dress in an exhibitionistic manner.
• Patients may be perceived as dependent,
  self-centered, hungry for admiration or praise,
  and manipulative.

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Clinical features - 3

• Somatization disorder is commonly associated with
  other mental disorders, including major
  depressive disorder, personality disorders,
  substance-related disorders, generalized anxiety
  disorder, and phobias.
• The combination of these disorders and the
  chronic symptoms results in an increased
  incidence of marital, occupational, and social
  problems.

15
Diagnosis criteria -1

• A. A history of many physical complaints that
  occur over a period of several years and result
  in treatment being sought or significant
  impairment in functioning beginning before age 30
• B. Each of the following must have been met, with
  individual symptoms occurring at any time during
  the course of the disturbance
• 4 pain symptoms
• 2 gastrointestinal symptoms
• 1 sexual symptom
• 1 pseudoneurological symptom

16
Diagnosis criteria -2

• four pain symptoms a history of pain related to
  at least four different sites or functions (e.g.,
  head, abdomen, back, joints, extremities, chest,
  rectum, during menstruation, during sexual
  intercourse, during urination)
• two gastrointestinal symptoms a history of at
  least two gastrointestinal symptoms other than
  pain (e.g., nausea, bloating, vomiting other than
  during pregnancy, diarrhea, or intolerance of
  several different foods)
• one sexual symptom a history of at least one
  sexual or reproductive symptom other than pain
  (e.g., sexual indifference, erectile or
  ejaculatory dysfunction, irregular menses,
  excessive menstrual bleeding, vomiting throughout
  pregnancy)
• one pseudoneurological symptom a history of at
  least one symptom or deficit suggesting a
  neurological condition not limited to pain
  (conversion symptoms such as impaired
  coordination or balance, paralysis or localized
  weakness, difficulty swallowing or lump in
  throat, aphonia, urinary retention,
  hallucination, loss of touch or pain sensation,
  double vision, blindness, deafness, seizures
  dissociative symptoms such as amnesia or loss of
  consciousness other than fainting

17
Diagnosis criteria -3

• C. Either 1 or 2
• 1. After appropriate investigation, each of the
  symptoms in Criterion B cannot be fully explained
  by a known GMC or substance
• 2. When there is a related GMC, the physical
  complaints or resulting social or occupational
  impairment are in excess of what would be
  expected from the history, physical examination,
  or laboratory findings.
• D. The symptoms are not intentionally produced or
  feigned (as in Factitious Disorder or Malingering)

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Differential diagnosis - 1

• nonpsychiatric medical conditions
• multiple sclerosis, myasthenia gravis, systemic
  lupus erythematosus, acquired immune deficiency
  syndrome (AIDS), acute intermittent porphyria,
  hyperparathyroidism, hyperthyroidism, and chronic
  systemic infections.
• Many mental disorders
• major depressive disorder, generalized anxiety
  disorder, and schizophrenia
• panic disorder
• other somatoform disorders
• hypochondriasis, conversion disorder, and pain
  somatization disorder,

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Differential diagnosis - 2

• Clinicians must always rule out nonpsychiatric
  medical conditions that may explain a patient's
  symptoms. Several medical disorders often show
  nonspecific, transient abnormalities in the same
  age group.
• These medical disorders include multiple
  sclerosis, myasthenia gravis, systemic lupus
  erythematosus, acquired immune deficiency
  syndrome (AIDS), acute intermittent porphyria,
  hyperparathyroidism, hyperthyroidism, and chronic
  systemic infections.
• The onset of multiple somatic symptoms in
  patients older than 40 should be presumed to be
  caused by a nonpsychiatric medical condition
  until an exhaustive medical workup has been
  completed.

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Differential diagnosis - 3

• Many mental disorders are considered in the
  differential diagnosis, which is complicated by
  the observation that at least 50 percent of
  patients with somatization disorder have a
  coexisting mental disorder.
• Patients with major depressive disorder,
  generalized anxiety disorder, and schizophrenia
  may all have an initial complaint that focuses on
  somatic symptoms.
• In all these disorders, however, the symptoms of
  depression, anxiety, or psychosis eventually
  predominate over the somatic complaints.
• Although patients with panic disorder may
  complain of many somatic symptoms related to
  their panic attacks, they are not bothered by
  somatic symptoms between panic attacks.

21
Differential diagnosis - 4

• Among the other somatoform disorders,
  hypochondriasis, conversion disorder, and pain
  somatization disorder, patients with
  hypochondriasis falsely believe that they have a
  specific disease, whereas those with somatization
  disorder are concerned with many symptoms.
• The symptoms of conversion disorder are limited
  to one or two neurological symptoms rather than
  to the wide-ranging symptoms of somatization
  disorder.
• Pain disorder is limited to one or two complaints
  of pain symptoms.

22
Course and prognosis

• chronic and often debilitating
• begun before age 30 and have been present for
  several years
• more than a year without seeking medical
  attention
• an association between periods of increased
  stress and the exacerbation of somatic symptoms.

23
Treatment

• regularly scheduled visits
• Additional laboratory and diagnostic procedures
  be avoided.
• emotional expressions
• Psychotherapy, both individual and group
• decreases personal health care expenditures
  (50)
• decreasing their rates of hospitalization.
• helped to cope with their symptoms
• to express underlying emotions
• to develop alternative strategies for expressing
  their feelings
• Giving psychotropic medications
• with coexisting mental disorders
• Medication must be monitored

24
Hypochondriasis
25
Introduction

• In DSM-IV, hypochondriasis is defined as a
  person's preoccupation with the fear of
  contracting, or the belief of having, a serious
  disease.
• This fear or belief arises when a person
  misinterprets bodily symptoms or functions.
• The term hypochondriasis is derived from the old
  medical term hypochondrium, ("below the ribs")
  and reflects the common abdominal complaints of
  many patients with the disorder.
• Hypochondriasis results from patients'
  unrealistic or inaccurate interpretations of
  physical symptoms or sensations, even though no
  known medical causes can be found.
• Patients' preoccupations result in significant
  distress to them and impair their ability to
  function in their personal, social, and
  occupational roles.

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Epidemiology and etiology

• One recent study reported a 6-month prevalence of
  hypochondriasis of 4 to 6 percent in a general
  medical clinic population.
• Men and women are equally affected by
  hypochondriasis.
• Although the onset of symptoms can occur at any
  age, the disorder most commonly appears in people
  20 to 30 years of age.
• Some evidence indicates that the diagnosis is
  more common among blacks than among whites, but
  social position, education level, and marital
  status do not appear to affect the diagnosis.

27
Clinical features-1

• Patients with hypochondriasis believe that they
  have a serious disease that has not yet been
  detected, and they cannot be persuaded to the
  contrary.
• They may maintain a belief that they have a
  particular disease as time progresses, they may
  transfer their belief to another disease.
• Their convictions persist despite negative
  laboratory results, the benign course of the
  alleged disease over time, and appropriate
  reassurances from physicians.
• Yet their beliefs are not so fixed as to be
  delusions.
• Hypochondriasis is often accompanied by symptoms
  of depression and anxiety and commonly coexists
  with a depressive or anxiety disorder.

28
Clinical features-2

• Although DSM-IV specifies that the symptoms must
  be present for at least 6 months, transient
  hypochondriacal states can occur after major
  stresses, most commonly the death or serious
  illness of someone important to the patient, or a
  serious (perhaps life-threatening) illness that
  has been resolved but that leaves the patient
  temporarily hypochondriacal in its wake.
• Such states that last fewer than 6 months should
  be diagnosed as somatoform disorder not otherwise
  specified.
• Transient hypochondriacal responses to external
  stress generally remit when the stress is
  resolved, but they can become chronic if
  reinforced by people in the patient's social
  system or by health professionals.

29
Diagnostic criteria-1

• The DSM-IV diagnostic criteria for
  hypochondriasis require that patients be
  preoccupied with the false belief that they have
  a serious disease and that the false belief be
  based on a misinterpretation of physical signs or
  sensations .
• The belief must last at least 6 months, despite
  the absence of pathological findings on medical
  and neurological examinations.
• The diagnostic criteria also stipulate that the
  belief not have the intensity of a delusion (more
  appropriately diagnosed as delusional disorder)
  and that it not be restricted to distress about
  appearance (more appropriately diagnosed as body
  dysmorphic disorder).
• The symptoms of hypochondriasis must be of an
  intensity that causes emotional distress or
  impairs the patient's ability to function in
  important areas of life.
• Clinicians may specify the presence of poor
  insight patients do not consistently recognize
  that the concerns about disease are excessive.

30
DSM-IV diagnosis criteria for ochondriasis

1. Preoccupation with fears of having, or the idea
   that one has, a serious disease based on the
   person-misinterpretation of bodily symptoms
2. The preoccupation persists despite appropriate
   medical evaluation and reassurance.
3. The belief in criterion A is not of delusional
   intensity (as in delusional disorder, somatic
   type) and is not restricted to a circumscribed
   concern about appearance (as in body dysmorphic
   disorder).
4. The preoccupation causes clinically significant
   distress or impairment in social, occupational,
   or other important areas of functioning.
5. The duration of the disturbance is at least 6
   months.
6. The preoccupation is not better accounted for by
   generalized anxiety disorder, obsessive-compulsive
   disorder, panic disorder, a major depressive
   episode, separation anxiety, or another
   somatoform disorder.

31
Differential diagnosis-1

• Hypochondriasis must be differentiated from
  nonpsychiatric medical conditions, especially
  disorders that show symptoms that are not
  necessarily easily diagnosed.
• Such diseases include AIDS, endocrinopathies,
  myasthenia gravis, multiple sclerosis,
  degenerative diseases of the nervous system,
  systemic lupus erythematosus, and occult
  neoplastic disorders.

32
Differential diagnosis-2

• Hypochondriasis is differentiated from
  somatization disorder by the emphasis in
  hypochondriasis on fear of having a disease and
  emphasis in somatization disorder on concern
  about many symptoms.
• A subtle distinction is that patients with
  hypochondriasis usually complain about fewer
  symptoms than do patients with somatization
  disorder.
• Somatization disorder usually has an onset before
  age 30, whereas hypochondriasis has a less
  specific age of onset.
• Patients with somatization disorder are more
  likely to be women than are those with
  hypochondriasis, which is equally distributed
  among men and women.

33
Differential diagnosis-3

• Hypochondriasis must also be differentiated from
  the other somatoform disorders.
• Conversion disorder is acute and generally
  transient and usually involves a symptom rather
  than a particular disease. The presence or
  absence of la belle indifference indifference is
  an unreliable feature with which to differentiate
  the two conditions.
• Pain disorder is chronic, as is hypochondriasis,
  but the symptoms are limited to complaints of
  pain.
• Patients with body dysmorphic disorder wish to
  appear normal but believe that others notice that
  they are not, whereas those with hypochondriasis
  seek out attention for their presumed diseases.

34
Differential diagnosis-4

• Hypochondriacal symptoms can also occur in
  patients with depressive disorders and anxiety
  disorders.
• If a patient meets the full diagnostic criteria
  for both hypochondriasis and another major mental
  disorder, such as major depressive disorder or
  generalized anxiety disorder, the patient should
  receive both diagnoses, unless the
  hypochondriacal symptoms occur only during
  episodes of the other mental disorder.
• Patients with panic disorder may initially
  complain that they are affected by a disease (for
  example, heart trouble), but careful questioning
  during the medical history usually uncovers the
  classic symptoms of a panic attack.
• Delusional hypochondriacal beliefs occur in
  schizophrenia and other psychotic disorders but
  can be differentiated from hypochondriasis by
  their delusional intensity and by the presence of
  other psychotic symptoms.
• In addition, schizophrenic patients' somatic
  delusions tend to be bizarre, idiosyncratic, and
  out of keeping with their cultural milieus.

35
Differential diagnosis-5

• Hypochondriasis is distinguished from factitious
  disorder with physical symptoms and from
  malingering in that patients with hypochondriasis
  actually experience and do not simulate the
  symptoms they report.

36
Course and prognosis

• The course of hypochondriasis is usually
  episodic the episodes last from months to years
  and are separated by equally long quiescent
  periods.
• There may be an obvious association between
  exacerbations of hypochondriacal symptoms and
  psychosocial stressors.
• Although well-conducted large outcome studies
  have not yet been reported, an estimated one
  third to one half of all patients with
  hypochondriasis eventually improve significantly.
• A good prognosis is associated with a high
  socioeconomic status, treatment-responsive
  anxiety or depression, the sudden onset of
  symptoms, the absence of a personality disorder,
  and the absence of a related nonpsychiatric
  medical condition.
• Most children with hypochondriasis recover by
  late adolescence or early adulthood.

37
Treatment-1

• Patients with hypochondriasis are usually
  resistant to psychiatric treatment although some
  accept this treatment if it takes place in a
  medical setting and focuses on stress reduction
  and education in coping with chronic illness.
• Among such patients, group psychotherapy is the
  modality of choice, in part because it provides
  the social support and social interaction that
  seem to reduce their anxiety.
• Individual insight-oriented psychotherapy may be
  useful, but is generally unsuccessful.

38
Treatment-2

• Frequent, regularly scheduled physical
  examinations are useful to reassure patients that
  their physicians are not abandoning them and that
  their complaints are being taken seriously.
• Invasive diagnostic and therapeutic procedures
  should only be undertaken, however, when
  objective evidence calls for them.
• When possible, the clinician should refrain from
  treating equivocal or incidental physical
  examination findings.

39
Treatment-3

• Pharmacotherapy alleviates hypochondriacal
  symptoms only when a patient has an underlying
  drug-responsive condition, such as an anxiety
  disorder or major depressive disorder.
• When hypochondriasis is secondary to another
  primary mental disorder, that disorder must be
  treated in its own right.
• When hypochondriasis is a transient situational
  reaction, clinicians must help patients cope with
  the stress without reinforcing their illness
  behavior and their use of the sick role as a
  solution to their problems.

40
Body dysmorphic disorder
41
Introduction-1

• DSM-IV defines body dysmorphic disorder as a
  preoccupation with an imagined defect (for
  example, a misshapen nose) or an exaggerated
  distortion of a minimal or minor defect in
  physical appearance.
• To be considered a mental disorder, the
  preoccupation must cause patients significant
  distress or be associated with impairment in the
  patient's personal, social, or occupational life.

42
Introduction-2

• The disorder was recognized and named
  dysmorphophobia more than 100 years ago by Emil
  Kraepelin, who considered it a compulsive
  neurosis Pierre Janet called it obsession de la
  honte du corps (obsession with shame of the
  body).
• Freud wrote about the condition in his
  description of the Wolf-Man, who was excessively
  concerned about his nose.
• Although dysmorphophobia was widely recognized
  and studied in Europe, it was not until the
  publication of DSM-III in 1980 that
  dysmorphophobia, as an example of a typical
  somatoform disorder, was specifically mentioned
  in the United States diagnostic criteria.
• In DSM-IV, the condition is known as body
  dysmorphic disorder, because the DSM editors
  believed that the term dysmorphophobia
  inaccurately implied the presence of a behavioral
  pattern of phobic avoidance.

43
Epidemiology

• The cause of body dysmorphic disorder is unknown.
  
• The high comorbidity with depressive disorders, a
  higher-than-expected family history of mood
  disorders and obsessive-compulsive disorder, and
  the reported responsiveness of the condition to
  serotonin-specific drugs indicate that in at
  least some patients the pathophysiology of the
  disorder may involve serotonin and may be related
  to other mental disorders.
• Stereotyped concepts of beauty emphasized in
  certain families and within the culture at large
  may significantly affect patients with body
  dysmorphic disorder.
• In psychodynamic models, body dysmorphic disorder
  is seen as reflecting the displacement of a
  sexual or emotional conflict onto a nonrelated
  body part.
• Such an association occurs through the defense
  mechanisms of repression, dissociation,
  distortion, symbolization, and projection.

44
Clinical features

• The most common concerns involve facial flaws,
  particularly those involving specific parts (for
  example, the nose).
• Sometimes the concern is vague and difficult to
  understand, such as extreme concern over a
  "scrunchy" chin.
• One study found that, on average, patients had
  concerns about four body regions during the
  course of the disorder. The specific body part
  may change during the time a patient is affected
  with the disorder.
• Common associated symptoms include ideas or frank
  delusions of reference , either excessive mirror
  checking or avoidance of reflective surfaces, and
  attempts to hide the presumed deformity.
• The effects on a person's life can be
  significant almost all affected patients avoid
  social and occupational exposure.
• As many as one third of the patients may be
  housebound because of worry about being ridiculed
  for the alleged deformities,
• and as many as one fifth attempt suicide.
• As previously discussed, comorbid diagnoses of
  depressive disorders and anxiety disorders are
  common, and patients may also have traits of
  obsessive-compulsive, schizoid, and narcissistic
  personality disorders.

45
Diagnosis criteria

1. Preoccupation with an imagined defect in
   appearance. If a slight physical anomoly is
   present, the person-concern is markedly
   excessive.
2. The preoccupation causes clinically significant
   distress or impairment in social, occupational,
   or other important areas of functioning.
3. The preoccupation is not better accounted for by
   another mental disorder (e.g., dissatisfaction
   with body shape and size in anorexia nervosa).

46
Diagnostic Criteria

• Preoccupation with an imagined defect in
  appearance. If a slight physical anomoly is
  present, the person-concern is markedly
  excessive.
• The preoccupation causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• The preoccupation is not better accounted for by
  another mental disorder (e.g., dissatisfaction
  with body shape and size in anorexia nervosa).

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47
Differential diagnosis-1

• Distortions of body image occur in anorexia
  nervosa, gender identity disorders, and some
  specific types of brain damage (for example,
  neglect syndromes) body dysmorphic disorder
  should not be diagnosed in these situations.
• Body dysmorphic disorder must also be
  distinguished from a person's normal concern
  about appearance.
• In body dysmorphic disorder, however, a person
  experiences significant emotional distress and
  functional impairment because of the concern.

48
Differential diagnosis-2

• Although distinguishing between a strongly held
  idea and a delusion is difficult, if a patient's
  preoccupation with the perceived body defect is,
  in fact, of delusional intensity, the appropriate
  diagnosis is delusional disorder, somatic type.
• Other diagnostic considerations are narcissistic
  personality disorder, depressive disorders,
  obsessive-compulsive disorder, and schizophrenia.
  
• In narcissistic personality disorder, concern
  about a body part is only a minor feature in the
  general constellation of personality traits.
• In depressive disorders, schizophrenia, and
  obsessive-compulsive disorder, the other symptoms
  of these disorders usually evidence themselves in
  short order, even when the initial symptom is
  excessive concern about a body part.

49
Course and prognosis

• The onset of body dysmorphic disorder is usually
  gradual.
• An affected person may experience increasing
  concern over a particular body part until the
  person notices that functioning is being
  affected.
• Then the person may seek medical or surgical help
  to address the presumed problem.
• The level of concern about the problem may wax
  and wane over time, although the disorder is
  usually chronic if left untreated.

50
Treatment

• Treatment of patients with body dysmorphic
  disorder with surgical, dermatological, dental,
  and other medical procedures to address the
  alleged defects is almost invariably
  unsuccessful.
• Although tricyclic drugs, monoamine oxidase
  inhibitors, and pimozide (Orap) have been
  reported to be useful in individual cases, a
  larger body of data indicate that
  serotonin-specific drugs-for example,
  clomipramine (Anafranil) and fluoxetine
  (Prozac)-are effective in reducing symptoms in at
  least 50 percent of patients.
• In any patient with a coexisting mental disorder,
  such as a depressive disorder or an anxiety
  disorder, the coexisting disorder should be
  treated with the appropriate pharmacotherapy and
  psychotherapy.
• How long treatment should be continued when the
  symptoms of body dysmorphic disorder have
  remitted is unknown.

51
Pain disorder
52
Introduction

• In DSM-IV, pain disorder is defined as the
  presence of pain that is "the predominant focus
  of clinical attention."
• Psychological factors play an important role in
  the disorder.
• The primary symptom is pain, in one or more
  sites, which is not fully accounted for by a
  nonpsychiatric medical or neurological condition.
  
• The symptoms of pain are associated with
  emotional distress and functional impairment.
• The disorder has been called somatoform pain
  disorder, psychogenic pain disorder, idiopathic
  pain disorder, and atypical pain disorder.

53
Epidemiology

• Low back pain has disabled an estimated 7 million
  people
• more than 8 million physician office visits
  annually
• Female male21
• The peak ages of onset are in the fourth and
  fifth decades
• most common in people with blue-collar
  occupations
• genetic inheritance or behavioral mechanisms are
  possibly involved

54
Clinical features-1

• Patients with pain disorder do not constitute a
  uniform group but, instead, are a heterogeneous
  collection of people with low back pain,
  headache, atypical facial pain, chronic pelvic
  pain, and other kinds of pain.
• A patient's pain may be posttraumatic,
  neuropathic, neurological, iatrogenic, or
  musculoskeletal to meet a diagnosis of pain
  disorder, however, the disorder must have a
  psychological factor that is judged to be
  significantly involved in the pain symptoms and
  their ramifications.

55
Clinical features-2

• Patients with pain disorder often have long
  histories of medical and surgical care.
• They visit many physicians, request many
  medications, and may be especially insistent in
  their desire for surgery.
• Indeed, they can be completely preoccupied with
  their pain and cite it as the source of all their
  misery.
• Such patients often deny any other sources of
  emotional dysphoria and insist that their lives
  are blissful except for their pain.
• Their clinical picture can be complicated by
  substance-related disorders, because these
  patients attempt to reduce the pain through the
  use of alcohol and other substances.

56
Clinical features-3

• At least one study has correlated the number of
  pain symptoms to the likelihood and severity of
  symptoms of somatization disorder, depressive
  disorders, and anxiety disorders.
• Major depressive disorder is present in about 25
  to 50 percent of all patients with pain disorder,
  
• and dysthymic disorder or depressive disorder
  symptoms are reported in 60 to 100 percent of the
  patients.
• Some investigators believe that chronic pain is
  almost always a variant of a depressive disorder,
  a masked or somatized form of depression.
• The most prominent depressive symptoms in
  patients with pain disorder are anergia,
  anhedonia, decreased libido, insomnia, and
  irritability diurnal variation, weight loss, and
  psychomotor retardation appear to be less common
  symptoms.

57
Diagnostic criteria

• The DSM-IV diagnostic criteria for pain disorder
  require the presence of clinically significant
  complaints of pain .
• The complaints of pain must be judged to be
  significantly affected by psychological factors,
  and the symptoms must result in a patient's
  significant emotional distress or functional
  impairment (for example, social or occupational).
  
• DSM-IV requires that the pain disorder be
  associated primarily with psychological factors
  or with both psychological factors and a general
  medical condition.
• DSM-IV further specifies that pain disorder
  associated solely with a general medical
  condition be diagnosed as an Axis III condition
  and also allows clinicians to specify whether the
  pain disorder is acute or chronic, depending on
  whether the duration of symptoms has been 6
  months or more.

58
DSM-IV diagnosis criteria for pain disorder

1. Pain in one or more anatomical sites is the
   predominant focus of the clinical presentation
   and is of sufficient severity to warrant clinical
   attention.
2. The pain causes clinically significant distress
   or impairment in social, occupational, or other
   important areas of functioning.
3. Psychological factors are judged to have an
   important role in the onset, severity,
   exacerbation, or maintenance of the pain.

1. ??????????????????????,??????????????
2. ?????????????????????????????
3. ??????????????????????????????

59
DSM-IV diagnosis criteria for pain disorder

1. The symptom or deficit is not intentionally
   produced or feigned (as in factitious disorder or
   malingering
2. The pain is not better accounted for by a mood,
   anxiety, or psychotic disorder and does not meet
   criteria for dyspareunia.

1. ???????????????(?????????????)?
2. ???????????????????,????????(????????)?

60
????

• ????????????
• ???????????????????????????,???????????(????????,?
  ??????????????????????,?????????????)?????????????
  ?,??????????????
• ???????????????????
• ???????????????????????????,?????????????????

61
Differential diagnosis-1

• Purely physical pain can be difficult to
  distinguish from purely psychogenic pain,
  especially because the two are not mutually
  exclusive.
• Physical pain fluctuates in intensity and is
  highly sensitive to emotional, cognitive,
  attentional, and situational influences.
• Pain that does not vary and is insensitive to any
  of these factors is likely to be psychogenic.
• When pain does not wax and wane and is not even
  temporarily relieved by distraction or
  analgesics, clinicians can suspect an important
  psychogenic component.

62
Differential diagnosis-2

• Pain disorder must be distinguished from other
  somatoform disorders, although some somatoform
  disorders can coexist.
• Patients with hypochondriacal preoccupations may
  complain of pain, and aspects of the clinical
  presentation of hypochondriasis, such as bodily
  preoccupation and disease conviction, can also be
  present in patients with pain disorder.
• Patients with hypochondriasis tend to have many
  more symptoms than do patients with pain
  disorder, and their symptoms tend to fluctuate
  more than do the symptoms of patients with pain
  disorder.
• Conversion disorder is generally short lived,
  whereas pain disorder is chronic. In addition,
  pain is, by definition, not a symptom in
  conversion disorder.
• Malingering patients consciously provide false
  reports, and their complaints are usually
  connected to clearly recognizable goals.

63
Course and prognosis

• The pain in pain disorder generally begins
  abruptly and increases in severity for a few
  weeks or months.
• The prognosis varies, although pain disorder can
  often be chronic, distressful, and completely
  disabling.
• When psychological factors predominate in pain
  disorder, the pain may subside with treatment or
  after the elimination of external reinforcement.
• The patients with the poorest prognoses, with or
  without treatment, have preexisting
  characterological problems, especially pronounced
  passivity are involved in litigation or receive
  financial compensation use addictive substances
  and have long histories of pain.

64
Treatment (1)

• General consideration
• discuss the issue of psychological factors early
  in treatment
• explain how various brain circuits that are
  involved with emotions
• fully understand that the patient's experiences
  of pain are real.
• Pharmacotherapy
• Analgesic medications are not generally helpful
• Sedatives and antianxiety agents are not
  especially beneficial
• Antidepressants (TCA, SSRIs) are useful
• Amphetamine used as an adjunct to SSRIs.

65
Treatment (2)

• Behavioral therapy
• Biofeedback can be helpful
• Hypnosis, transcutaneous nerve stimulation, and
  dorsal column stimulation have been used
• Nerve blocks and surgical ablative procedures are
  ineffective
• Psychotherapy
• develop a solid therapeutic alliance
• not confront somatizing patients
• examine its interpersonal ramifications in the
  patient's life
• Cognitive therapy

66
Treatment (3)

• Pain control programs
• Multidisciplinary pain units use many modalities
• physical therapy and exercise
• offer vocational evaluation and rehabilitation
• Concurrent mental disorders are diagnosed and
  treated
• dependent on analgesics and hypnotics are
  detoxified.

67
Neurasthinia
68
Introduction-1

• The term neurasthenia was introduced in the 1860s
  by the American neuropsychiatrist George Miller
  Beard, who applied it to a condition
  characterized by chronic fatigue and disability.
• The term neurasthenia ("nervous exhaustion") is
  not now used frequently, but it does appear in
  psychiatric literature and remains a diagnostic
  entity in the 10th revision of International
  Statistical Classification of Diseases and
  Related Health Problems (ICD-10).

69
Introduction-2

• In ICD-10, neurasthenia is classified as one of
  the neurotic disorders.
• According to current nosology in the United
  States, the disorder is not considered a distinct
  diagnosis.
• In the fourth edition of Diagnostic and
  Statistical Manual of Mental Disorders (DSM-IV),
  neurasthenia is categorized as undifferentiated
  somatoform disorder.

70
Introduction-3

• The disorder is a prime example of cultural
  differences influencing the classification and
  manifestations of diseases.
• Neurasthenia is an accepted condition in Europe
  and Asia, where it is characterized by fatigue,
  headache, insomnia, and other vague somatic
  complaints and is thought to result from chronic
  stress rather than from unconscious psychological
  conflicts.
• In many cultures (especially China), in which
  people resist being categorized as having a
  mental disorder, neurasthenia is a preferred
  diagnosis. Thus, the disorder is most commonly
  diagnosed in eastern Asia.

71
Epidemiology-1

• Difficulties in investigating the epidemiology of
  neurasthenia stem from the fact that it occurs in
  connection with other conditions, such as
  anxiety, depression, and somatoform disorders,
  and it has not been sufficiently studied as an
  independent disorder.
• Beard considered neurasthenia one of the most
  frequently observed conditions in the 19th
  century United States, although no statistics
  were available to support his observation.
• A 1994 study in Switzerland showed a prevalence
  rate (using ICD-10) of 12 percent in that
  country.

72
Epidemiology-2

• Studies have indicated that the major
  symptoms-fatigue and heightened concerns with
  bodily symptoms-are most commonly appear in
  people who are socially and economically
  deprived, although the disorder is no more
  prevalent in this group than in others and may,
  in fact, occur more frequently in higher
  socioeconomic groups.
• Precursors of neurasthenia in the form of
  "growing pains," fatigue, and sleep disturbances
  appear in children.
• Beard believed childhood to be one of the peak
  periods for the onset of the disorder, the other
  being middle age (adults 40 to 65 years of age).

73
Diagnostic criteria-1

• According to ICD-10, neurasthenia is not used as
  a diagnostic category in all countries.
• In the United States, for example, many of the
  cases so diagnosed would meet the criteria for
  depressive disorder, somatoform disorder, or
  anxiety disorder.
• Some patients, however, have such varied symptoms
  that neurasthenia is the preferred diagnosis.
• These patients may be diagnosed using the ICD-10
  diagnostic criteria, or they may receive a
  diagnosis of undifferentiated somatoform disorder
  according to the DSM-IV criteria.

74
Diagnostic criteria-2

• Neurasthenia is characterized by a wide variety
  of signs and symptoms.
• The most common findings are chronic weakness and
  fatigue, aches and pains, and general anxiety or
  "nervousness."
• Beard, Freud, and others described a plethora of
  patients' reported complaints. The symptoms are
  real to patients.
• As Beard stated "They are not imaginary. They
  have a real objective existence and cannot be
  willed away."

75
Diagnostic criteria-3

• ICD-10 describes two types of the disorder, with
  substantial overlap between them.
• In one type, the main feature is a complaint of
  increased fatigue after mental effort, often
  associated with some decrease in occupational
  performance or coping efficiency in daily tasks.
  The mental fatigability is typically described as
  an unpleasant intrusion of distracting
  associations or recollections, difficulty in
  concentrating, and generally inefficient
  thinking.
• In the other type, the emphasis is on feelings of
  bodily or physical weakness and exhaustion after
  only minimal effort, accompanied by muscular
  aches and pains and inability to relax.
• In both types, other unpleasant physical
  feelings, such as dizziness, tension headaches,
  and a sense of general instability, are common.
  Worry about decreasing mental and bodily
  well-being, irritability, anhedonia, and varying
  degrees of both depression and anxiety may be
  present. Sleep is frequently disturbed in its
  initial and middle phases, but hypersomnia may
  also be prominent.

76
Diagnostic criteria-4

• If the DSM-IV criteria are used, neurasthenia
  would be associated with one of the two forms of
  undifferentiated somatoform disorders,
• that is, with the group of physical complaints
  including chronic fatigue and loss of appetite.

77
Signs and symptoms reported by patients with
neurasthenia

• General fatigue
• Exhaustion
• General anxiety
• Difficulty concentrating
• Physical aches and pains
• Dizziness
• Headache
• Intolerance of noise (hyperacusis) or bright
  lights
• Chills
• Indigestion
• Constipation or diarrhea
• Flatulence
• Palpitations
• Extrasystole
• Tachycardia
• Excess sweating
• Flushing of skin
• Dysmenorrhea

• Sexual dysfunction, eg, erectile disorder,
  anorgasmia
• Paresthesia
• Insomnia
• Poor memory
• Pessimism
• Chronic worry
• Fear of disease
• Irritability
• Feelings of hopelessness
• Dry mouth or hypersalivation
• Arthralgias
• Heat insensitivity
• Dysphagia
• Pruritus
• Tremors
• Back pain

78
Differential Diagnosis-1

• Neurasthenia must be distinguished from anxiety
  disorders, depressive disorder, and the
  somatoform disorders, which include somatization
  disorder, conversion disorder, hypochondriasis,
  body dysmorphic disorder, and pain disorder.
• Because so many signs and symptoms of
  neurasthenia overlap with and appear in each of
  these disorders, differential diagnosis may be
  exceedingly difficult.
• For example, patients with anxiety disorder do
  not uncommonly have depressive symptomatology
• patients with hypochondriasis often complain of
  anxiety
• and patients with body dysmorphic disorder can
  have somatic complaints.

79
Differential Diagnosis-2

• Clinicians must rigorously apply the diagnostic
  criteria for anxiety, depressive, and somatoform
  disorders before making a diagnosis of
  neurasthenia.
• Hallmarks of neurasthenia are a patient's
  emphasis on fatigability and weakness and concern
  about lowered mental and physical efficiency (in
  contrast to the somatoform disorders, in which
  bodily complaints and preoccupation with physical
  disease dominate the picture).
• If the neurasthenic syndrome develops in the
  aftermath of a physical illness (particularly
  influenza, viral hepatitis, or infectious
  mononucleosis), the diagnosis of the illness
  should also be recorded. Chronic fatigue
  syndrome, discussed below, must also be
  considered.

80
Course and prognosis-1

• Neurasthenia most often occurs during adolescence
  or middle age.
• Untreated, the disorder is usually chronic, and
  patients may become incapacitated by one or more
  symptoms so that all areas of functioning become
  impaired.
• In childhood, difficulties in school functioning,
  including poor grades and truancy, are likely.
• In adulthood, work performance deteriorates, or
  patients may become so disabled that work is
  impossible.
• Similarly, social, marital, and interpersonal
  relationships suffer.

81
Course and prognosis-2

• Beard believed that with treatment (such as it
  was in the 1860s) "the majority can be relieved
  or substantially cured."
• The range of therapeutic options now available is
  broad, and with treatment the prognosis should be
  favorable but the long-term prognosis is
  unknown.
• For cases first diagnosed in childhood, the
  prognosis without treatment is guarded,
  chronicity of symptoms being the most likely
  outcome.
• Sometimes it is difficult to distinguish the
  prodromal signs of schizophrenia or bipolar
  disorder from neurasthenia.

82
Treatment-1

• The key concept in the current treatment of
  neurasthenia is clinicians' understanding that a
  patient's symptoms are not imaginary.
• The symptoms are objective and are produced by
  emotions that influence the autonomic nervous
  system, which in turn affects body functions.
• Stress can cause structural change in an organ
  system, and the result can be life threatening.
• Therapy must therefore begin with a careful
  medical workup to determine whether a patient's
  somatic symptoms are amenable to therapy, and if
  so, what treatment is likely to produce the best
  results.
• Patients should be reassured that the
  administration of medication (analgesics,
  laxatives, and so on) to relieve medical symptoms
  will be successful, but only when combined with
  concurrent psychotherapeutic intervention.
• Patients must be helped to recognize the stresses
  in their lives and the coping mechanisms they use
  to deal with these stresses, to gain insight into
  the interaction between mind and body. Without
  such insight-oriented psychotherapy, the
  neurasthenic condition is likely to continue
  unabated.

83
Treatment-2

• The availability of psychopharmacological agents
  has markedly improved therapeutic options.
• Serotonergic agents (such as fluoxetine
  Prozac), which have both an antidepressant and
  an antianxiety effect, are the most useful class
  of drugs. Newer antidepressants, such as
  nefazodone (Serzone) and mirtazapine (Remeron),
  are also effective.
• Mirtazapine is reported to have distinct
  sedative properties in addition to being an
  antidepressant and may be especially useful for
  neurasthenia.
• Physicians should take care in prescribing drugs
  with abuse potential, such as benzodiazepines,
  because of these patients' predilection for
  self-medication and drug misuse.
• Such drugs may be useful, for brief periods and
  under careful supervision, to deal with
  overwhelming anxiety, phobias, or insomnia.
  Similarly, small doses of analeptics, such as
  amphetamine (Dexedrine) or methylphenidate
  (Ritalin), may help to treat chronic fatigue and
  anhedonia.
• Testosterone replacement can be tried in men with
  demonstrated testosterone deficiency, but
  long-term treatment with testosterone is
  associated with serious adverse side effects,
  such as prostatic cancer.